Application for Payment of Medicare Premiums, Coinsurance and Deductibles [PDF]

The PA 600M is a mail-in application for payment of the Medicare Part B premium only. It is used to help elderly individuals or individuals with disabilities who are eligible for Medicare to pay some or all of their Medicare Part B premium. A face-to-face interview is not required when using this application. The application cannot be used to apply for Medicaid (Medical Assistance), cash assistance or food stamps. (PA 600 M (AS) 8/19)

Last Review and Update: Sep 27, 2023
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